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Oliveira BGD, Costa VHRD, Gama IR, Beskow MH, Santos ERSD. Diagnosis and Prevention of Periprosthetic Joint Infections by Staphylococcus aureus after Hip Fracture: A Systematic Review of the Literature. Rev Bras Ortop 2024; 59:e21-e28. [PMID: 38524719 PMCID: PMC10957261 DOI: 10.1055/s-0043-1776019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/08/2022] [Indexed: 03/26/2024] Open
Abstract
Hip arthroplasties are surgical procedures widely performed all over the world, seeking to return functionality, relieve pain, and improve the quality of life of patients affected by osteoarthritis, femoral neck fractures, osteonecrosis of the femoral head, among other etiologies. Periprosthetic joint infections are one of the most feared complications due to the high associated morbidity and mortality, with a high number of pathogens that may be associated with its etiology. The aim of the present study was to analyze aspects correlated with the occurrence of infection, diagnosis and prevention of periprosthetic joint infections in the hip associated with Staphylococcus aureus after corrective surgery for hip fractures. This is a systematic review of the literature carried out in the databases indexed in the Medical Literature Analysis and Retrieval System Online (MEDLINE) carried out in accordance with the precepts established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Twenty studies that addressed the diagnosis and prevention of periprosthetic joint infections after hip fractures were selected for analysis. It is observed that there is no consensus in the literature on preventive measures for the occurrence of such infectious processes. Among the risk factors for the occurrence and severity of infections by S. aureus after hip arthroplasties, obesity, longer surgical time, older age, immunosuppression, recent use of antibiotics, and multicomorbidities were mentioned. The use of biomarkers for early diagnosis, as well as screening, decolonization, and antibiotic prophylaxis processes are among the preventive procedures proposed in the literature.
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Affiliation(s)
- Bianca Gabriella de Oliveira
- Departamento da Liga Acadêmica de Ortopedia e Traumatologia da UNIFACS, Universidade Salvador (UNIFACS), Salvador, BA, Brasil
| | | | - Igor Rodrigues Gama
- Serviço de Ortopedia e Traumatologia, Hospital Universitário de Canoas, Canoas, RS, Brasil
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Ashkenazi I, Thomas J, Lawrence KW, Rozell JC, Lajam CM, Schwarzkopf R. Positive Preoperative Colonization With Methicillin Resistant Staphylococcus Aureus Is Associated With Inferior Postoperative Outcomes in Patients Undergoing Total Joint Arthroplasty. J Arthroplasty 2023; 38:1016-1023. [PMID: 36863576 DOI: 10.1016/j.arth.2023.02.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND The impact of preoperative nasal colonization with methicillin resistant staphylococcus aureus (MRSA) on total joint arthroplasty (TJA) outcomes is not well understood. This study aimed to evaluate complications following TJA based on patients' preoperative staphylococcal colonization status. METHODS We retrospectively analyzed all patients undergoing primary TJA between 2011 and 2022 who completed a preoperative nasal culture swab for staphylococcal colonization. Patients were 1:1:1 propensity matched using baseline characteristics, and stratified into 3 groups based on their colonization status: MRSA positive (MRSA+), methicillin sensitive staphylococcus aureus positive (MSSA+), and MSSA/MRSA negative (MSSA/MRSA-). All MRSA+ and MSSA + underwent decolonization with 5% povidone iodine, with the addition of intravenous vancomycin for MRSA + patients. Surgical outcomes were compared between groups. Of the 33,854 patients evaluated, 711 were included in final matched analysis (237 per group). RESULTS The MRSA + TJA patients had longer hospital lengths of stay (P = .008), were less likely to discharge home (P = .003), and had higher 30-day (P = .030) and 90-day (P = .033) readmission rates compared to MSSA+ and MSSA/MRSA-patients, though 90-day major and minor complications were comparable across groups. MRSA + patients had higher rates of all-cause (P = .020), aseptic (P = .025) and septic revisions (P = .049) compared to the other cohorts. These findings held true for both total knee and total hip arthroplasty patients when analyzed separately. CONCLUSION Despite targeted perioperative decolonization, MRSA + patients undergoing TJA have longer lengths of stay, higher readmission rates, and higher septic and aseptic revision rates. Surgeons should consider patients' preoperative MRSA colonization status when counseling on the risks of TJA.
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Affiliation(s)
- Itay Ashkenazi
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York; Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Jeremiah Thomas
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Kyle W Lawrence
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
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Li T, Zhang H, Chan PK, Fung WC, Fu H, Chiu KY. Risk factors associated with surgical site infections following joint replacement surgery: a narrative review. ARTHROPLASTY 2022; 4:11. [PMID: 35490250 PMCID: PMC9057059 DOI: 10.1186/s42836-022-00113-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/31/2021] [Indexed: 11/17/2022] Open
Abstract
Background Surgical site infection following joint replacement surgery is still a significant complication, resulting in repeated surgery, prolonged antibiotic therapy, extended postoperative hospital stay, periprosthetic joint infection, and increased morbidity and mortality. This review discusses the risk factors associated with surgical site infection. Related risk factors The patient-related factors include sex, age, body mass index (BMI), obesity, nutritional status, comorbidities, primary diagnosis, living habits, and scores of the American Society of Anesthesiologists physical status classification system, etc. Surgery-related factors involve preoperative skin preparation, prolonged duration of surgery, one-stage bilateral joint replacement surgery, blood loss, glove changes, anti-microbial prophylaxis, topical anti-bacterial preparations, wound management, postoperative hematoma, etc. Those risk factors are detailed in the review. Conclusion Preventive measures must be taken from multiple perspectives to reduce the incidence of surgical site infection after joint replacement surgery.
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Affiliation(s)
- Tao Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Haining Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ping Keung Chan
- Department of Orthopaedics &, Traumatology Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong SAR, China.
| | - Wing Chiu Fung
- Department of Orthopaedics &, Traumatology Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong SAR, China
| | - Henry Fu
- Department of Orthopaedics &, Traumatology Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong SAR, China
| | - Kwong Yuen Chiu
- Department of Orthopaedics &, Traumatology Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong SAR, China
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Ingall EM, Grisdela PT, Bejarano-Pineda L, DiGiovanni CW. To Screen or Not to Screen. . . Who Nose? Foot Ankle Int 2022; 43:453-456. [PMID: 34794341 DOI: 10.1177/10711007211052294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Eitan M Ingall
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
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Kapur BP, Tonge X, Kumar G. Risk of methicillin-resistant staphylococcus aureus prosthetic joint infection in elective total hip and knee arthroplasty following eradication therapy. World J Orthop 2021; 12:842-849. [PMID: 34888144 PMCID: PMC8613691 DOI: 10.5312/wjo.v12.i11.842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/08/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a devastating complication requiring prolonged treatment and multiple operations, leading to significant morbidity for the patient. Patients are routinely tested for methicillin-resistant staphylococcus aureus (MRSA) colonisation. MRSA positive patients are given eradication therapy. We hypothesise that patients who are MRSA positive pre-operatively, have increased risk of developing PJI.
AIM To identify deep wound infection (PJI) rates in patients who are colonised MRSA positive compared with those who are not colonised; and long term clinical and radiological outcomes.
METHODS All patients who underwent total hip and knee replacements (THR/TKR) between December 2009 and December 2019 were identified. Patients who were also identified as being MRSA positive at pre-operative assessment were then selected. Confirmation of prescribing eradication treatment was recorded. Patient records, including consultation letters, operation notes and microbiology results were reviewed retrospectively. Comparison of outcomes for each MRSA positive patient was made with 2 MRSA negative patients undergoing the same operation of a similar age by the same consultant.
RESULTS Screening identified 42 knee and 32 hip arthroplasty patients as MRSA positive, 84 MRSA negative knee and 64 hip patients were reviewed. Patients were matched with medical co-morbidities in each group. Mean follow up was 5 years. PJI was identified in 4/32 (12.5%) of THR MRSA positive and 3/42 (7%) of TKR patients. All patients had PJI within one year of surgery.
CONCLUSION MRSA positive patients are given eradication therapy routinely. However, no confirmation of eradication is sought. Patients who have MRSA colonisation pre-operatively, in our study had a significantly increased risk of PJI, when compared to negative patients. We would recommend establishing true eradication after treatment prior to arthroplasty.
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Affiliation(s)
- Benjamin Pal Kapur
- Trauma and Orthopaedics, Royal Liverpool University Teaching Hospitals, Liverpool L7 8XP, Merseyside, United Kingdom
| | - Xenia Tonge
- Trauma and Orthopaedics, Royal Liverpool University Teaching Hospitals, Liverpool L7 8XP, Merseyside, United Kingdom
| | - Gunasekaran Kumar
- Trauma and Orthopaedics, Royal Liverpool University Teaching Hospitals, Liverpool L7 8XP, Merseyside, United Kingdom
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Ribau AI, Collins JE, Chen AF, Sousa RJ. Is Preoperative Staphylococcus aureus Screening and Decolonization Effective at Reducing Surgical Site Infection in Patients Undergoing Orthopedic Surgery? A Systematic Review and Meta-Analysis With a Special Focus on Elective Total Joint Arthroplasty. J Arthroplasty 2021; 36:752-766.e6. [PMID: 32950342 DOI: 10.1016/j.arth.2020.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Staphylococcus aureus is a major pathogen implicated in orthopedic infections worldwide. Preoperative decolonization has been promoted but different strategies present mixed results. Thus, the goals of this study are to determine (1) whether S aureus screening and/or decolonization is effective at reducing surgical site infection in orthopedic surgery, (2) with a special focus on elective total joint arthroplasty (TJA), and (3) which preoperative S aureus screening/treatment strategy is most cost-effective for TJA. METHODS PubMed, Ovid MEDLINE, and Cochrane databases were searched on January 1, 2020, using a systematic strategy. We included papers with data comparing surgical site infection and periprosthetic joint infection rate in orthopedic surgery and/or elective total hip and knee arthroplasty patients before/after S aureus screening and/or decolonization protocol and papers evaluating the cost-effectiveness of different S aureus screening/treatment strategies. RESULTS A total of 1260 papers were screened, and 32 papers were ultimately included. Results showed an increased risk of developing any infection (relative risk [RR] = 1.71 ± 0.16) and S aureus infection (RR = 2.79 ± 0.45) after orthopedic surgery without previous nares and whole-body decolonization. Focusing exclusively on elective TJA, there was an increased risk of developing any infection (RR = 1.70 ± 0.17) and S aureus infection (RR = 2.18 ± 0.41) if no decolonization is performed. All strategies appeared to be cost-effective, although universal decolonization without screening seemed to be the most advantageous. CONCLUSION Preoperative S aureus screening/decolonization protocol lowered the risk of infection after elective orthopedic and TJA surgeries. However, further studies are needed to determine optimal clinical and cost-effective methodologies.
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Affiliation(s)
- Ana I Ribau
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal
| | - Jamie E Collins
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ricardo J Sousa
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal; Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar do Porto and Grupo TrofaSaude - Hospital em Alfena, Portugal
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Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining. J Clin Med 2020; 9:jcm9072190. [PMID: 32664491 PMCID: PMC7408657 DOI: 10.3390/jcm9072190] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.
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Åkesson P, Chen AF, Deirmengian GK, Geary M, Quevedo MS, Sousa R, Springer BD, Wang Q. General Assembly, Prevention, Risk Mitigation, Local Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S49-S53. [PMID: 30360980 DOI: 10.1016/j.arth.2018.09.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Cizmic Z, Feng JE, Huang R, Iorio R, Komnos G, Kunutsor SK, Metwaly RG, Saleh UH, Sheth N, Sloan M. Hip and Knee Section, Prevention, Host Related: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S255-S270. [PMID: 30348549 DOI: 10.1016/j.arth.2018.09.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Bondarenko S, Chang CB, Cordero-Ampuero J, Kates S, Kheir M, Klement MR, McPherson E, Morata L, Silibovsky R, Skaliczki G, Soriano A, Suárez R, Szatmári A, Webb J, Young S, Zimmerli W. General Assembly, Prevention, Antimicrobials (Systemic): Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S61-S73. [PMID: 30348584 DOI: 10.1016/j.arth.2018.09.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Inabathula A, Dilley JE, Ziemba-Davis M, Warth LC, Azzam KA, Ireland PH, Meneghini RM. Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate. J Bone Joint Surg Am 2018; 100:2103-2109. [PMID: 30562290 DOI: 10.2106/jbjs.17.01485] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended antibiotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients. METHODS A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p ≤ 0.05 indicating significance. RESULTS The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extended antibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis. CONCLUSIONS Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Julian E Dilley
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Lucian C Warth
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Khalid A Azzam
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Philip H Ireland
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - R Michael Meneghini
- Indiana University Health Orthopedics, Indianapolis, Indiana.,Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Affiliation(s)
- Mengnai Li
- The Ohio State University, Columbus, Ohio
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